Intensive Care Unit (ICU) nurses’ experiences while supporting families following the deaths of their critically-ill relatives
Nurses working in critical care units can experience certain traumatic events while supporting families that have lost their loved ones. The environment of the critical care unit exposes nurses to deaths of patients repeatedly either when the patient is in his active dying stages or when he is facing inevitable death. Thus, intensive care unit (ICU) nurses can encounter challenges to cope with the stress that results from supporting dying patients or their families (Naidoo and Sibiya 2014).
Wenham and Pittard (2009) opined that the environment of an ICU is intimidating, fearful and frightening for the patients as well as the medical practioners. Similarly, working as an ICU nurse can be also dreadful and requires courage and personal strength to overcome the challenges in this unit. Decisions making, intensely complicated environments and moral dilemmas are all a part of a critical care unit’s unique setting (Scholtz et al. 2016). Moreover, the hospital staffs have to give their best effort to ease the pain of their patients in all the circumstances and the focus of both the staff and the family of a patient has to primarily be the patient only. The patients regardless of their health status and prognosis either transit to death or come back to life from the edge of the everlasting sickness. According to Topcu et al. (2017), ICU refers to a place where patients with impaired survivor functions and in the need of additional technology, close follow-ups and intense medications along with care to enable them to make use of their normal functions are kept. More the positive and intensive care will be, more likely the facilitation of the patient’s well-being will be after his discharge and consequently, lesser will be the contingency towards any negative change in the quality of his life (Topcu et al. 2017).
Critical care unit
Naidoo and Sibiya (2014) pointed out that with the advancement in technology, the ICUs should be entirely dedicated towards saving lives of numerous patients by the means of specialized surgical and disease management techniques. Further, Wenham and Pittard (2009) confirmed that an ICU is a potentially combative environment for critically ill patients and recommended that the environment of an ICU must be improved through critical staff education, modification of equipments and careful consideration of the future design of an ICU. In addition to this, Alameddine et al. (2009) suggested that improvement of an ICU should focus on the strategies for enhancing patient care, recruitment and retention of a competent workforce and these strategies should seek to improve experiences in the professional, physical and emotional environments.
Backes, Erdmann and Büscher (2015) elicited that numerous aspects of care have to be considered in a caring environment. Such an environment comprises of various sets of elements integrating it, all of which have to be taken into account in way identical to how little parts that include a whole. However, these elements are rarely considered in a biomedical healthcare model, which mainly emphasise on the disease, knowledge fragmentation, being and acting professionally and at times, not even the entity that is cared for, having numerous social relationships and potentiated by various social and natural environments is perceived as an integrated whole (Backes, Erdmann and Büscher 2015).
Furthermore, a caring environment calls for conditions that are favourable for health, promoting healthy and constructive environments with harmony and thereby enhancing interpersonal relationships that increase the likelihood of better living through positive energies. Although often stigmatised, an ICU has the capacity to create erroneous inceptions related to care and the attitude of a team. Correspondingly, Backes, Erdmann and Büscher (2015) demonstrated that ICU is perceived as an environment establishing contradictory sensations, myths and feelings, such as pain, sadness and anger, and insecurities and sufferings in both patient and his family along with the working professionals in the unit. Alharbi and Alshehry (2019) reported that in Saudi Arabia, religious belief is the most frequently used mechanism for coping from the ICU related stress and anxiety.
Critical care nurses
Critical/intensive care nursing is a field of practice aimed at offering patient’s care for those facing life-threatening emergencies, acute injuries, and/or critical illnesses (American Association of Critical Care Nurses 2016). American Association of Critical Care Nurses (2016) highlights that in their provision of providing care to critically ill patients, the critical care nurses require the aid of technology and advanced problem-solving capabilities. Critical care nurses need to utilize specialized knowledge concerning a human response to critical illnesses. As per the American Association of Critical Care Nurses (2016), critical care nursing broadly refers to nurses working in step-down units, post-anaesthesia recovery rooms, cardiac care units, emergency departments and ICUs. These nurses carry out planning, education, implementation, management and advocacy in meeting the patients’ and their families’ needs. For the purposes of this paper, the term ‘critical care units’ nursing will refer to the ‘ICU nurses’ in order to avoid confusion with other professions. Kisorio and Langley (2016) demonstrated that however, critical care nurses and physicians provide care for patients with critical illnesses with the aim of function restoration and life-saving, evidence exists that nearly twenty percent of critically ill patients end up dying annually in an ICU. Majority of these deaths involve the withdrawal or withholding of therapies that were previously used for life sustenance. Given the complexity of the care needs of those in an ICU, mortality rates can be higher than in other care settings. The complication of illness, including multi-organ failure and irreversible neurological injury may result in the withdrawal or intervention of critical care. In such situations, roles of ICU nurses get shifted from the provision of life sustenance care to end of life care (EOLC). The percentage of ICU nurses involved in EOLC differs from situation to situation (Kisorio and Langley 2016).
Noome et al. (2016) elucidated that EOLC refers to the services providing caring and supporting services to seriously ill patients and their families once the decision of ending the ongoing treatment(s) has been made. In an ICU, EOLC has seven quality domains. Primarily, the decisions regarding EOLC must be patient and family centred. Noome et al. (2016) further stated that ICU nurses are responsible for communication with patients and families and that ICU nurses should guarantee continuity of care. Moreover, ICU nurses should provide practical and emotional support to the patient and his family. The nurses should also provide comforting care and proper symptom management. Additionally, the ICU nurses should provide spiritual support also and the organisations where ICU nurses work, there should be a provision of providing organisational and emotional support to the professionals (Noome et al. 2016).
The United States, like any other global nations is experiencing an increase in the number of deaths occurring in ICUs and 1 in 5 Americans meet their deaths during ICU services (Espinosa et al. 2010). In Europe, 6-27% of all the ICU patients die while in the US, 10-29% dies in an ICU. Netherlands has ICU patient deaths percentage close to 8%, while in the three Scandinavian nations of Finland, Norway, and Sweden have a combined 9.1%. At least 85% of these deaths occur upon withholding or withdrawing treatments supporting life and with the increasing number of critically ill patients; there is an expected rise in the decisions to withdraw life supporting therapies (Noome et al. 2016). According to Espinosa et al. (2010), the US experiences close to 2.5 million deaths annually approximately 60% of which occur in hospitals and about half of them in the ICUs. Ranse et al. (2012) demonstrated that the mortality rates in the ICUs have grown to about 20% and a significant component of the intensive care nurses' responsibilities is the end-of-life care. For the patients in the ICU, the nurses' responsibility is to offer specific care to both the patients and their families. Ranse et al. (2012) further pointed out that the nurses are expected to deal with the uncertainty and ambiguity around patient prognosis and treatment. In a culture characterized by death as a perception of failure, EoLC provision can result in unmet carer and patient needs leading to ICU nurses experiencing stress and burnout. Additionally, in Middle-Eastern countries such as Iran and Saudi Arabia, where various cultural beliefs can also influence the provision of EoLC, which can further hinder the ability of an ICU nurse to fulfill the requirements of a dying patient (Mani and Ibrahim 2017).
According to Martins and Robazzi (2009), the work in the ICU is intricate. The complexity arises from patients being regarded as critical and presenting forthcoming life risks. Unlike other health care service providers, the numerous procedures and technological devices needed on the patients create an environment acknowledged as traumatizing and aggressive. Further, Martins and Robazzi (2009) revealed that the constant presence of death and the stress on the health team only encourages the feeling of suffering implicating is the development of work-related stress following nurses working with pain, suffering, and witnessing deaths. Martins and Robazzi (2009) confirmed that the suffering among ICU nurses is also associated with working constantly in an unstable clinical condition that triggers weariness.
Sufferings of ICU nurses hinder the provision of quality care provided to the ICU patients (Shimizu et al. 2011). According to Shimizu et al. (2011), the ICU nurse is always expected to make decisions at speed, prioritize actions with a heightened sense of responsibility, resolve complex issues, manage the vast and changing amount of information, and continuously reorganize activities amidst constant interruptions. Besides the deaths of patients, the nursing team frequently faces the death and sufferings of their fellow nurses, and the ambivalent feelings from the patients and their family members. The result is the invariable provocation of feelings of intense anxiety contributing to the establishment of mediation strategies as an effort to avoid tensions that cumulatively lurk the veracity or their health (Shimizu et al. 2011).
Nurses’ experiences in the ICUs
In an intensive care unit, nurses ought to provide the most aggressive care to the most critically ill patients along with minute-by-minute monitoring (Espinosa et al. 2010). According to Espinosa et al. (2010), the number of patients receiving terminal care in ICUs is increasing as a result of which, the experiences of stressful situations at work are also increasing. These lead to the sufferings of ICU nurses and a lack of their psycho-emotional balance (Shimizu et al., 2011). The work performed by the nursing team is associated with numerous health injuries, which can be attributed to the organizational context (Espinosa et al. 2010). These health injuries include burnouts, stress factors, need for improved communication skills and others. The ICU nurses have to confront with the sufferings, pain and deaths of their patients. According to Bruziene (2005), nurses experience emotional and physical stress along with psychological strain. Later Akinwolere (2016) confirmed that the psychological stress in the workplace is a global phenomenon and that this phenomenon could influence an ICU nurse’s social life, work and home.
Depression, which is a consequence of stress, has an estimated cost about forty four billion dollars annually for the lost productivity of ICU nurses. The amount of stress has grown from 59% to 74% from the year 2006 to 2007 respectively. Akinwolere (2016) revealed that the American Psychological Association has predicted a public health crisis induced by stress. Some of the causes of psychological stress include new health care facilities settings, insufficient skills and knowledge, expanding responsibilities, and changing regulations and rules in an organization. In another study conducted on 154 ICU nurses in Saudi Arabia, 87% of the respondents were reported stressed in the preceding month (Alharbi and Alshehry 2019). ICU nurses are amongst those professionals in the healthcare sector that are most likely susceptible towards attaining stress in the workplace (Akinwolere 2016).
Preto and Pedrao (2009) defined stress as an association with discomforting sensations. The number of people defining themselves as stressed is growing day by day. This is because the emotional reactions among ICU nurses vary depending on situations and individual standpoints. Preto and Pedrao (2009) also confirmed that the nursing occupation is a stressful occupation where ICU nurses have to work with people in need of sympathy, attention, and compassion. In such situations, nurses may end up disappointed, irritated and depressed. According to Preto and Pedrao (2009), these feelings are regarded as paradoxically incompatible with their professional performance, increasing anxiety, and establishing guilt. The situation of ICU nurses worsens with the increasing quest for improved quality of patient care. They also elucidated that the ICU nurses have to work surrounded by an adequate psychological and physical environment where there are skills to apply and take advantage of present techniques, to perform challenging activities. These activities comprise of heavy work schedules, and excellent practical demands, and physical theoretical and mental preparation, given that the units are environments where patients receive intensive and direct care following serious illnesses or injuries risking their lives (Preto and Pedrao 2009). ICUs are incredibly stressful situations as a consequence of the consistent expectations of emergencies, complexity of high technology, and concentration of severity of injury in patients following sudden changes in patient general health status. During work hours, an ICU nurse’s emotional profile undergoes changes in the course of their shifts. The alterations arise from care giving stress and weariness and, above all, demands for high-level skills and immediate responses (Preto and Pedrao 2009). In addition to this, Preto and Pedrao (2009) pointed out that other factors attributed to ICU nurses’ stress are environments characterized by artificial lighting, refrigeration, excessive dryness, and sealing; internal noise that can be interrupted or continuous; excessive demands for responsibility, security, and respect, and stable inter-relationships between teammates during their shifts.
ICU nurses can get all sorts of emotions while working, such as the feeling of anger, guilt, grief, and emotional sadness following emotional depersonalization and exhaustion (Costa and Moss 2018). These feelings, as revealed by Costa and Moss (2018), later become the symptoms of burnout syndrome, which is the response by the individual to a given work-oriented event, manifesting in people without baseline psychological disorders. Costa and Moss (2018) highlighted that however, burnout syndrome is often a gradual process, the most terrifying symptoms are depersonalization and lowered personal achievements. In order for burnout to present itself, an individual must experience divergence between his expectations from himself and his roles, and the expectations of the organization or employer and his role (Costa and Moss 2018). Costa and Moss (2018) stated that compared to other nurses, ICU nurses experience the highest burnout rates and around 86% can be diagnosed with it. Burnout impacts ICU nurses negatively in terms of their work satisfaction and general care (Costa and Moss 2018). There is a need to assist ICU nurses to deal with burnout and other forms of emotional and psychological stress (Chuang et al., 2016). The creation of a resilient health system calls for extensive efforts towards addressing burnout among healthcare professionals, especially the ICU nurses.
Purpose of this research study
Despite engaging in such an essential role, there is a little social recognition accorded to the ICU nurses. According to Shimizu et al. (2011), ICU nurses’ roles are invisible and undervalued by the patients and other professionals. Additionally, there has been penalization of the nursing care in public health institutions with material and human resources deficiencies that directly affect the quality of care given to the people. Furthermore, Shimizu et al. (2011) highlighted that the intensity of suffering experienced while working in the ICU can be the result of constantly being exposed to stressful situations and that these stressful situations are characterized unconsciously in accordance with the work psychodynamics, shared and individual experiences originating from the conflict between work desired by the organization and the individuals. Consequently, the nurses are manifested with distress as emotional, social and physical exhaustion and when exacerbated, distress in ICU nurses translates to personality impoverishment, causing emotional numbness in the individual such that their emotional manifestation is erased (Shimizu et al., 2011). Shimizu et al. (2011) elicited that these experiences of distress among ICU nurses result in failure when one has to confront their feelings leading to the ICU nurses disguise their own painful emotional experiences and psychic suffering from themselves.
According to Mealer et al. (2006), ICU nurses’ distress is the result of exposure to traumatic events and compared to other nurses, the ICU nurses undergo increased existence of post-traumatic stress disorder (PTSD) symptoms. PTSD symptoms include avoidance of reminders of events, persistent recollections, and increased arousals (Mealer et al. 2006). Moreover, the patients that survive ICU stay have a high chance of experiencing PTSD symptoms and that their families too can experience mild to moderate PTSD, especially given their participation in end-of-life care (EOLC) discussions and decisions. The ICU nurse is thus obliged to ensure that the family remains informed about the treatment and represents their values and patient preferences (Mealer et al. 2006).
In summary, ICU nurses work in an environment that presents outstanding challenges and opportunities. Pre-existing studies offer some insight into the ICU nurse's experiences while supporting families in end-of-life-care. However, further research is needed to offer a deeper understanding of ICU nurses’ experiences while supporting families following the death of a critically ill relative. This present study seeks to add to the previous findings till date via obtaining a literature review of the previous studies from all over the world to help explore the cultural barriers faced by ICU nurses during interaction with families following the death of a patient in the Middle East, especially Saudi Arabia where a certain restricted culture is prevalent. Restrictive culture includes the prohibition of close contact with families during the provision of emotional support through activities such as hugging or touching. Since not all ICU nurses are aware of Saudi culture, and they pose the language and religious barriers.
Furthermore, the goal of this study is to understand the psychological effects of interacting with families in the process of caring for the patients’ families after the patient has died. Considering the fact that Saudi Arabian culture is unique and the patients there require special treatment that is computable with their beliefs, this paper aims to provide future guidance to the researchers having interest in this topic. Hence, this research aims to intensely contribute in exploring the challenges that an ICU nurse could face in supporting the families of patients who have died in a restrictive culture having language and religious barriers.
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